Accreditation Council for Graduate Medical Education

Residency Review Committee Update

APDVS and Residency Coordinators Meeting Chicago, ILApril 16, 2010

Peggy Simpson, EdDExecutive DirectorResidency Review Committees for Surgery

RRC—Surgery Members

• Thomas V. Whalen, MD, Chair•

• J. Patrick O’Leary, MD, Vice Chair

• Adeline Deladisma, MD, Resident

• Timothy R. Billiar, MD

• G. Patrick Clagett, MD

• Peter J. Fabri, MD

• Linda M. Harris, MD

• George W. Holcomb, MD

• James C. Hebert, MD

• Mark A. Malangoni, MD

• Marshall V. Schwartz, MD

• Charles W. Van Way III, MD

• Marc K. Wallack, MD

• Frank Lewis, MD, Ex-Officio ABS

• Patrice Blair, MPH, Ex-Officio ACS

Compliance Assessed by Residency Review Committee (Specialty Committee)

Types of Accreditation Standards

Specialty-SpecificProgram Requirements

Common Program RequirementsCompliance

Assessed byInstitutional Review Committee

InstitutionalRequirements

Navigating the Requirements*

1. Must: A term used to identify a requirement which is mandatory or done without fail. This term indicates an absolute requirement.

2. Shall: (See must)

3. Should: Term used to designate requirements so important that their absence must be justified. A program or institution may be cited for failing to comply with a requirement that includes the term ‘should’.

*From ACGME “Glossary of Terms” (acgme.org)

Accreditation Decisions

Continued Accreditation

ProbationProbation

Continued Accreditation

Accreditation Accreditation WithdrawnWithdrawn

Accreditation Accreditation WithheldWithheld

Initial Accreditation

Continued Accreditation

Accreditation Accreditation WithdrawnWithdrawn

Application

Defer

• RRC needs clarification of major issues

• Accreditation decision remains “open”

• Result: Additional information will be requested. RRC will consider request after information has been received.

Progress Reports

• RRC needs a response to major concerns

• Report must be:• Responsive• Reviewed/signed by the institution’s DIO

• Sent only when requested

Progress Reports: Reasons to Request

• RRC seeks improvement/attention to an issue and believes site visit is not necessary to bring issue to a state of compliance with program requirements.

• RRC sees an issue has reoccurred over time and believes progress report will focus program and institutional attention on the issue.

Notification of RRC Decisions

• 2-4 days after RRC meeting (informal notification via e-mail)

• 60 days after RRC meeting (formal Letter of Notification (LON) posted)

• LONS are available only through ADS

• Notifications sent to PD and DIO of record.

Preparing for your Site Visit

• Start Early

• Ensure Annual Update is accurate• Faculty Information• Resident Information• Participating Site Information

• When in doubt, let us know.

Resident Duty Hours

80 hour limit - averaged over 4 weeks, includes in-house call

1. One day our of seven free 2. In-house call no more than 1 day in 3 averaged over

4 weeks3. 24-hour duty maximum4. Provide at least 10 hours for rest between duty

periods5. In-house moonlighting counts

Monitoring Duty Hour Compliance

• Non-compliant Programs Identified through:• Program Self-reports• Resident Questionnaire• Resident Complaints

• Actions taken by RRCs:• Additional Monitoring (change in Site Visit date)• Requests for Progress Reports• Shortened Accreditation Cycle

Resident Complements

• Temporary or Permanent??

• Changes to Resident Complements• To request change to total number• To request change to number at a PGY level• Any reallocation must be approved by RRC

prior to implementation

Surgery RRC 2010 Program Status

Specialty# of

AccreditedPrograms

Full Accreditation

InitialAccreditation

ProbationaryAccreditation

General Surgery 249 237 5 7

Vascular Surgery -Independent

101 90 10 1

Vascular Surgery -Integrated

24 2 22 0

Surgical Critical Care 97 83 14 0

Pediatric Surgery 38 32 6 0

Hand Surgery 1 1 0 0

Totals 510 445 57 8

Surgery RRC 2010 Program Data

Specialty Total # Programs

Total # Approved Residents

Total # Filled

Residents

%age of Filled/

Approved

General Surgery 249 8372 7395 89.01%

Vascular Surgery -Independent

101 266 246 92.48%

Vascular Surgery -Integrated

24 120 40 33.33%

Surgical Critical Care 97 214 156 72.89%

Pediatric Surgery 38 76 72 94.73

Hand Surgery 1 8 8 100%

Totals 510 9056 7917 87.42%

Site Visit Results 2009

• Common Citations • Evaluation– Residents, Faculty, Program• Procedural Experience• Duty Hours

Surgery RRC Vascular Surgery

Programs Surveyed 121 33

Administrative Requests 120 13

Citations Issued 237 44

Citations/Program 1.91 1.33

Average Cycle Length 3.43 3.55

RRC 2009 Top 10 Citations

Vascular Surgery 2009:Top Citations

Evaluation and the Competencies

1. Educational G&Os

2. Clinical & Didactic Experiences

4. Assess Outcomes—analyze evaluation results; refine G&Os, take additional actions; add improvements

3. Evaluation Activities (observer, 360, self, etc.)

Tools for Evaluation

Evaluation Tools

Evaluation Tools (cont)

Example Evaluation Tool

Agenda Closing Dates

• Meeting: June 24-25, 2010Agenda Closing: April 15, 2010

• Meeting: October 28-29, 2010• Agenda Closing: August 19, 2010

• Meeting: February 24-25, 2011• Agenda Closing: December 16, 2011

• Meeting: June 23-24, 2011• Agenda Closing: April 14, 2011

Program Information Form Updates

• Scholarly Activities• Resident Activities• Faculty Activities• Conferences

PIF Updates (cont.)

• RESIDENT PUBLICATIONS• abstracts/publications• presentations (local, regional, national)• grand rounds• basic science• multidisciplinary institutional educational conferences • dedicated research experience (protected time)

teaching awards• teaching skills lab session• formal medical student teaching (i.e. anatomy

courses, scientific and/or clinical lectures)

PIF Updates (cont.)

• FACULTY INFORMATION• Basic Science Research

• Educational Research (includes development of teaching materials)

• Faculty Name• Project Name• Funded• Not Funded

 

PIF Updates (cont.)

• CONFERENCES• Basic and Clinical Sciences• Grand Rounds• Morbidity and Mortality Conferences• Multidisciplinary (e.g., pediatric radiology,

surgical pathology and tumor conferences)• Faculty/Resident Name• Title of Presentation• Frequency• Sessions Presented (Y/N)• Sessions Directed (Y/N)• Site #

RRC Surgery Resources

• www.acgme.org (Review Committee Surgery page)

• Program requirements• PIFs• Newsletters

When to Contact ACGME via ADS

• Progress Report requested• Upcoming changes in program - All requests

must be made through ADS

• Notify change in Program Director and/or PD contact information

• Request any change resident complement• Request participating site changes (add or delete)• Request changes to approved rotations

• Response to Citations• Annual Updates

When to Contact Staff

• Any time you need clarification and/or consultation

• Any time major changes are occurring

• Change in sponsorship/ownership

RRC Surgery Staff Contact Information

• Peggy Simpson, EdD, Executive Director312.755.5499 psimpson@acgme.org

• Cathy Ruiz, MA, Senior Accreditation Administrator 312.755.5495 cruiz@acgme.org

• Allean Morrow-Young, Accreditation Assistant312.755.5038 amh@acgme.org